Tri Cities Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cumberland, Kentucky.
- Location
- 19101 Us Highway 119 North, Cumberland, Kentucky 40823
- CMS Provider Number
- 185433
- Inspections on file
- 16
- Latest survey
- October 11, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Tri Cities Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to ensure the dietary department was managed by a qualified director, affecting 67 of 69 residents. The Dietary Manager (DM) was not a Certified Dietary Manager (CDM) and had no prior management experience. The Registered Dietitian (RD) confirmed the DM's lack of certification and encouraged her to complete the necessary courses.
The facility failed to follow menus and portion control guidelines, affecting 67 out of 69 residents. Observations revealed unapproved food substitutions and incorrect scoop sizes used for serving meals. The Dietary Manager admitted to not having the correct menus, and the Registered Dietitian confirmed the use of incorrect scoop sizes. The Administrator was unaware of these issues, which could impact the nutritional adequacy and palatability of meals.
The facility failed to maintain proper food safety practices, affecting 67 residents. Food items were not dated or labeled, and temperature logs were incomplete. Unlabeled food and improper storage of utensils posed risks of food-borne illnesses and cross-contamination. The issues were confirmed by the Dietary Manager and reported to the Administrator and DON.
The facility failed to properly dispose of and contain garbage, affecting 69 residents and staff. Observations revealed dumpsters with lids off, exposing contents, and debris around the area, attracting bears. The Maintenance Director noted daily cleaning efforts and ineffective animal control measures. The Administrator confirmed the lack of a formal policy on this issue.
The facility failed to ensure staff used proper PPE while cleaning dumpsters disturbed by bears, posing an infection control risk. The Maintenance Director cleaned without PPE, and the Infection Preventionist and Director of Housekeeping acknowledged the issue. The Administrator and DON were unaware of the situation.
The facility failed to ensure residents and/or their representatives were invited to participate in care plan meetings, as required. Six residents' records lacked evidence of invitations or participation in quarterly care conferences. The Social Services Director admitted to only sending invitations annually or upon significant changes, unaware of the quarterly requirement. The Administrator and DON acknowledged the failure to conduct quarterly care plan meetings and the lack of documentation of invitations.
Two residents, one severely and one moderately cognitively impaired, engaged in a physical altercation in the smoking area, resulting in minor injuries. The facility's failure to implement its abuse prevention policy led to this incident, as confirmed by records and staff interviews.
A resident with severe cognitive impairment and multiple diagnoses did not receive prescribed Mighty Shakes with meals, leading to significant weight loss. Facility staff failed to document the administration of the supplements, and the resident was not re-weighed as per policy. The Dietary Manager was unaware of the weight loss, and the Registered Dietitian's recommendations were not followed.
A facility failed to provide trauma-informed care to a resident with PTSD, schizoaffective disorder, and other conditions. The resident's care plan did not address PTSD, and staff were unaware of the diagnosis. The Social Services Director did not document the resident's mental health history, and the DON expected staff to assess PTSD triggers, which was not done.
A resident with moderate cognitive impairment and complete dependence on staff was found to have side rails in use without proper assessment, care plan, or informed consent. Observations and staff interviews confirmed the lack of necessary documentation, and facility leadership acknowledged the oversight.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.14% error rate. One resident with COPD was not prompted to rinse his mouth after receiving an inhaled steroid, and another resident with diabetes did not have the insulin pen needle left in place for the required time. Both errors were acknowledged by the staff involved, and the DON and Administrator confirmed the expectation for adherence to medication administration guidelines.
Unqualified Dietary Management in Facility
Penalty
Summary
The facility failed to ensure that the dietary department was managed by a qualified director of food and nutrition services, which had the potential to affect 67 of the 69 residents living at the facility. The deficiency was identified through document review, interviews, and policy review. The 2022 Food Code US FDA requires that the person in charge be a certified food protection manager, which was not the case at this facility. The facility's own document titled 'Food Service Manager' also indicated the need for a certified food protection manager. The Dietary Manager (DM) was hired as a cook and later transitioned to a weekend manager role, with plans to become a full-time manager and begin testing for her dietary credentials as a Certified Dietary Manager (CDM). However, the DM confirmed she had no prior management experience in a nursing facility and was not far along in her studies for the CDM exam. The Registered Dietitian (RD) confirmed that the DM was not a CDM and had encouraged her to complete the necessary courses. The RD did not supervise the current DM, and the Administrator and Director of Nursing stated that the RD would provide additional training to the DM.
Menu and Portion Control Deficiencies
Penalty
Summary
The facility failed to ensure that menus and menu extensions were followed, which included providing appropriate approved food substitutions, ensuring recipes were followed, and proper scoop sizes were utilized for 67 out of 69 residents. During an initial tour of the kitchen, it was observed that Cook1 replaced lima beans with pinto beans without evidence of an approved substitution. The Dietary Manager (DM) admitted that the menu for the week was incorrect and that the kitchen staff did not have the correct menus to follow. Additionally, the DM acknowledged that beef bouillon was available but not used, which could affect the nutritional adequacy of pureed meat dishes. Further observations revealed that incorrect scoop sizes were used for serving various food items, such as pureed beef, pinto beans, mashed potatoes, and ground fried steak. The DM and the Registered Dietitian (RD) confirmed that the wrong scoop sizes were used, which deviated from the standard practice outlined in the menu extension. The Administrator was unaware of these discrepancies and acknowledged that using water instead of bouillon could affect the palatability and caloric content of the food served.
Food Safety Deficiencies in Kitchen and Storage Areas
Penalty
Summary
The facility failed to ensure proper food safety practices in the kitchen and storage areas, affecting 67 out of 69 residents. Observations revealed that food items were not consistently dated and labeled, and food temperature logs were incomplete. Specifically, temperature logs for breakfast, lunch, and dinner were missing entries for several days in September 2024. The Registered Dietitian had previously discussed the importance of maintaining these logs with the Dietary Manager to prevent food from entering unsafe temperature zones. During a kitchen tour, it was found that several food items in the reach-in refrigerator were not labeled or dated, including cooked cabbage, mandarin oranges, and other perishable items. Additionally, scoops were left in containers of cereal, posing a risk of cross-contamination. The Dietary Manager confirmed these issues, acknowledging the potential for food-borne illnesses, especially for residents with compromised immune systems. The Administrator and Director of Nursing were informed of these concerns, which highlighted lapses in food safety protocols.
Improper Garbage Disposal and Containment
Penalty
Summary
The facility failed to ensure proper disposal and containment of garbage, which had the potential to affect 69 residents and staff. During an initial tour of the kitchen, two outside dumpsters were observed with lids off the hinges, exposing the contents. Debris, including old food, soup containers, disposable cups, and used adult briefs, was found both inside and outside the fenced area, emitting a strong odor. A Dietary Aide noted that bears would climb over the fence, pulling or tossing trash bags, which they then tore apart. The Maintenance Director stated that he cleaned the area daily and mentioned that animal control did not assist with managing the bears. He also noted that the dumpster lids could be fixed and that the electric deterrent on the fence was ineffective against the bears. During an interview, the Administrator confirmed the expectation for the area around the dumpster to be cleaned but acknowledged the absence of a formal policy addressing this issue.
Inadequate PPE Use During Dumpster Cleanup
Penalty
Summary
The facility failed to ensure that staff donned appropriate personal protective equipment (PPE) while cleaning the outside of two facility dumpsters, which posed a potential infection control issue. During an observation, it was noted that the Maintenance Director (MD) cleaned up trash scattered by bears without wearing any PPE except for latex gloves. The trash included used adult incontinence briefs and food waste, which could carry bacteria such as salmonella and E. coli. The MD acknowledged the risk of carrying bacteria back into the facility. Dietary Aides confirmed that the MD did not wear PPE during the cleanup process. The Infection Preventionist (IP) was aware of the bear activity but was unaware that staff were not using PPE, recognizing this as a potential infection control issue. The Director of Housekeeping also noted that her staff, who took out trash to the dumpsters, sometimes assisted in cleaning without wearing rubber boots, which could lead to contamination. The Administrator and the Director of Nursing (DON) were unaware of the situation, indicating a lack of communication and oversight regarding infection control practices related to the cleanup of bear-disturbed trash.
Failure to Conduct and Document Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were invited to participate in the development or revision of their care plans, as required. This deficiency was identified for six residents out of a sample of 23. The facility's policy mandates documentation of invitations to care conferences in the progress notes, and if a resident or their representative chooses not to participate, this should also be noted. However, the records for these residents lacked evidence of such invitations or participation in care planning meetings. For Resident 3, the electronic medical record did not show any evidence of invitations or participation in quarterly care conferences, despite the resident being moderately cognitively impaired. Similarly, Resident 19's records also lacked documentation of invitations or participation in care conferences. The Social Services Director admitted to only sending invitations annually or upon significant changes, unaware of the quarterly requirement. Resident 46, who was cognitively intact, also did not have any care plan meetings documented, with the Director of Nursing confirming no meetings had been held. Resident 56 had not had a care plan meeting since January 2023, and the facility had not followed up on an invitation sent in August 2024. Resident 1's records showed no care planning meetings since March 2024, and the resident's father, who was the medical decision-maker, stated he had not received any invitations. Resident 8, who was moderately cognitively impaired, had not had a care plan meeting since March 2022, and the Social Services Director confirmed that meetings were not held if residents declined. The Administrator and Director of Nursing acknowledged the failure to conduct quarterly care plan meetings and the lack of documentation of invitations.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents, R15 and R48, from physical abuse, resulting in a physical altercation between them in the smoking area. R48, who was severely cognitively impaired, and R15, who was moderately cognitively impaired, engaged in a confrontation that led to both residents sustaining minor injuries. The incident occurred when R15 attempted to direct R48 to a specific spot, leading to a physical exchange. Both residents were separated by staff, and minor first aid was administered for scratches. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the altercation between R15 and R48. The facility's records, including incident logs and investigation summaries, confirmed the occurrence of the altercation and the subsequent injuries. Interviews with staff and residents indicated that this was the first incident of its kind between these two residents, and the facility's administration acknowledged the expectation that residents should not be subjected to abuse.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to provide a resident, identified as R38, with the recommended and physician-prescribed nutritional interventions to prevent weight loss. R38, who was severely cognitively impaired and had diagnoses including heart disease, chronic kidney disease, and acute respiratory failure, was ordered to receive a regular diet with Mighty Shakes, a nutritional supplement, with each meal. However, documentation from the Medication Administration Record, Treatment Administration Record, and Certified Nursing Assistant daily documentation revealed that R38 did not receive the Mighty Shakes as ordered, and there was no record of refusal by the resident. Observations and interviews confirmed that R38 was not receiving the Mighty Shakes with meals. Certified Nursing Assistants familiar with R38 indicated that the resident was not on the list of those receiving supplements and that the resident did not receive the shakes consistently. The Dietary Manager was unaware of R38's weight loss and did not follow up on the Registered Dietitian's recommendations until receiving an order from the nursing staff. The Registered Dietitian confirmed that her recommendations for Mighty Shakes were communicated weekly to the Director of Nursing and the Dietary Manager, but the facility staff did not document the administration of the supplements. The facility's policy required re-weighing residents after significant weight changes, but R38 was not re-weighed after a 5.65% weight loss in two weeks. The Registered Dietitian was not informed of the deviation from the recommended plan of care, which included the administration of Mighty Shakes. The Director of Nursing and the Administrator stated that their expectation was for residents to be re-weighed with any significant weight loss and for the Registered Dietitian's recommendations to be followed.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to a resident diagnosed with PTSD, among other conditions. The resident, who had right side paralysis and was aphasic, was admitted with a history of stroke, schizoaffective disorder, bipolar disorder, depression, anxiety, and chronic PTSD. Despite these diagnoses, the facility did not develop a care plan addressing the resident's PTSD or identify specific traumatic events. The resident's medical record lacked a trauma-informed care approach, and sections related to mental health history were left blank in assessments. Interviews with facility staff revealed a lack of awareness and understanding of the resident's psychiatric diagnoses. A CNA and an RN were unaware of the resident's PTSD diagnosis, and the Social Services Director admitted to not documenting the resident's mental health history. The Director of Nursing expressed that staff should assess residents with PTSD for causes and triggers, but this was not done for the resident in question. This oversight had the potential to affect the resident's quality of life by not addressing their trauma-related needs.
Failure to Assess and Document Use of Side Rails
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the use of side rails, had a care plan in place, and obtained informed consent for their use. The resident, who was moderately cognitively impaired and completely dependent on staff for movement and transfers, was observed with side rails in use on her bed. However, there was no documentation in the resident's medical records, including the Admission Record, Minimum Data Set, Order Summary Report, or comprehensive care plan, indicating an assessment or informed consent for the use of side rails. Observations confirmed the presence of side rails, and staff interviews revealed that the resident was unable to use the rails for movement or transfers. The Registered Nurse responsible for ensuring the necessity of bedrails acknowledged the lack of assessment, care plan, and informed consent documentation. The Director of Nursing and the Administrator also confirmed that the resident's use of side rails had not been properly documented, indicating a lapse in the facility's procedures.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.14% error rate during the survey. Two specific incidents contributed to this deficiency. In the first incident, a resident with chronic obstructive pulmonary disease (COPD) was administered an inhaled steroid medication, Tiotropium Bromide Monohydrate (Spiriva), without being prompted to rinse his mouth afterward. This oversight was observed during a medication administration by a Certified Nursing Assistant/Kentucky Medication Assistant (CNA/KMA), who later admitted to being unaware of the need for the resident to rinse his mouth after using the inhaler. In the second incident, a resident with type two diabetes was administered insulin using a Kwikpen Insulin Pen. The Registered Nurse (RN) administering the insulin failed to leave the needle inserted in the resident's subcutaneous tissue for the required amount of time to ensure full absorption of the medication. The RN acknowledged the mistake, stating she believed the needle should have been left in place for 10 seconds but did not do so. The Director of Nursing (DON) and the facility Administrator confirmed that the expectation was for medications to be administered according to established guidelines and procedures.
Latest citations in Kentucky
The facility failed to maintain an effective pest control and sanitation program, resulting in a widespread gnat infestation in common areas, resident halls, the laundry room, medication cart trash, dirty utility room, and the kitchen. Surveyors observed gnats emerging from drains, stagnant mop water with a rancid odor, and extensive moisture, standing water, and organic debris in kitchen drains, cracked floor tiles, and hard-to-reach areas behind equipment. Pest control service reports over several months repeatedly documented unresolved issues such as drain debris, standing water, and debris accumulation, while the pest control provider stated that facility compliance with recommended cleaning and maintenance was inconsistent and many action items remained undone. The Dietary Manager reported ongoing gnat problems and use of a hose-mounted floor sprayer and vinegar in drains, which the pest control representative stated would not remove organic buildup or larvae. Leadership, including the VPO, DON, and Administrator, described expectations for cleaning, pest reporting, and drain use that were not reflected in observed conditions, and two residents reported that gnats were frequently present around them and their food, especially during meals.
A resident with morbid obesity and bilateral foot drop, whose care plan called for two staff for bed mobility and incontinence care, slid off the edge of the bed during perineal care and sustained abrasions and skin discoloration. The resident stated an SRNA rolled them too far while the SRNA was on the opposite side of the bed, and staff interviews confirmed the SRNA performed the care alone instead of waiting for another staff member. The ADON and DON stated the resident should have had two staff assist with the care.
An LPN was observed administering insulin via a pen injector to a resident with diabetes without priming the needle before either dose. The resident had type 2 DM with hyperglycemia and active NovoLog FlexPen orders, but the facility’s competency assessment covered insulin by syringe and did not show training or assessment for insulin pen use. The LPN stated she was not aware priming was required, and the DON and Administrator confirmed the facility had not provided competency training on insulin pens.
A resident admitted for rehab with muscle weakness and unsteadiness had PT and OT care plans and orders for treatment five times per week, but therapy logs showed missed PT/OT sessions on two days with no documented reason. The Director of Rehabilitation confirmed the resident received therapy only three of five days over two consecutive weeks, contrary to the plan of care, and could not explain or document why sessions were missed. The resident and the resident’s representative reported that the resident did not receive therapy as expected, that therapy minutes were insufficient, and that services were not tailored to the resident’s needs, including use of group therapy despite the resident’s stated preference against it.
The facility failed to maintain a safe, clean, and sanitary laundry environment and to properly manage a resident’s clothing. A resident with COPD, heart failure, type 2 DM, and ESRD had most of their clothing lost during a short stay, and the family member who searched for the items described the laundry room as extremely hot, messy, dirty, with clothes everywhere and overflowing trash. Staff interviews confirmed the laundry room had long‑standing issues with excessive heat and clutter. Surveyor observations found floors between and behind washers covered with dirt, a dry flaky substance, loose concrete, and residue on piping and chemical tubing, alongside buckets of corrosive chemicals. Interviews with housekeeping, EVS, a chemical vendor, and maintenance showed that a chemical spill behind the washers had occurred over a year earlier and was never properly cleaned up, with conflicting accounts over whether maintenance or EVS was responsible and no effective system to ensure cleaning behind the machines.
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident with mild cognitive impairment and multiple medical conditions was reported by the resident’s family member. The Administrator was notified of the allegation that someone had smacked the resident across the face, but the initial report to the state survey agency was not submitted until more than three and a half hours later, exceeding the required two-hour timeframe. Facility documentation did not show that law enforcement was notified, despite policy requiring reporting of suspected crimes, and interviews with the SSD, DON, and Administrator confirmed that the expected practice was to report such allegations promptly to the state survey agency and law enforcement when applicable.
Two residents reported serious allegations—one of missing money and identification and another of being slapped by a staff member—but the facility failed to conduct comprehensive investigations as required by its abuse policy. In the misappropriation case, a cognitively intact resident named a specific staff member by first name, and the schedule showed an SRNA with that name worked during the alleged timeframe, yet that SRNA was never interviewed or asked for a statement, and the DON acknowledged not knowing the investigative process. In the physical abuse case, a resident with mild cognitive impairment reported being slapped and told a family member that a manager over the office was responsible, but the facility obtained statements only from some floor staff, did not interview office staff, did not obtain statements from all staff who worked the relevant shifts, and limited resident interviews and skin assessments to one hall. These actions and omissions resulted in incomplete investigations of both abuse-related allegations.
A resident with dementia, osteoporosis, a right artificial hip, and severe cognitive impairment was care planned as dependent for bed mobility, toileting, and transfers, with an intervention requiring two staff for assistance. Despite this, an SRNA, who knew the resident was a two-person assist, began perineal care alone and rolled the resident onto the side, causing the resident to roll out of bed and fall. An LPN obtained stat x-rays that showed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where surgery was performed and the resident later died on a hospice unit. Staff interviews confirmed that the two-person assist requirement had been in place for years and that the failure to follow the care plan led to the incident.
A resident with dementia, osteoporosis, and a right artificial hip joint, assessed as severely cognitively impaired and dependent for bed mobility, toileting, and transfers, had a care plan and Kardex requiring a two-person assist for these ADLs. An SRNA, despite knowing this requirement, began perineal care alone and rolled the resident onto her side, causing the resident to roll out of bed onto the floor. The incident report and IDT identified the root cause as failure to follow the Kardex, with contributing factors including the resident’s weakness and history of falls. An LPN and unit manager found the resident on the floor, obtained stat x-rays that revealed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where imaging confirmed a comminuted, moderately displaced femoral fracture and an ORIF procedure was performed. Staff interviews confirmed that the resident had long required a two-person assist and that only one staff member was present at the time of the incident, and also revealed that nurses and managers had not routinely spot checked SRNAs for adherence to the care plan/Kardex prior to the event.
A resident with intact cognition and multiple comorbidities developed fever and abnormal urinalysis results consistent with a UTI, for which an NP ordered a single 3 g dose of Fosfomycin. The MAR showed the antibiotic order and later an entry placing it on hold due to unavailability from pharmacy, without a corresponding provider order or documentation explaining the delay or who was contacted. The medication was not administered until four days after the original order, during which time the resident reported going without treatment and later required ED transfer, where a complicated UTI was diagnosed and treated with IM Rocephin and Toradol.
Failure to Maintain Effective Pest Control and Sanitary Conditions Resulting in Widespread Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of insects and other pests, resulting in a widespread gnat infestation throughout the building. Surveyor observations over two days identified gnats in multiple common areas, including the conference room, resident halls, laundry room, medication cart trash can, and dirty utility room. In the laundry room, gnats were seen emerging from the washing machine discharge drain, and in the dirty utility room, gnats were concentrated around a mop bucket containing stagnant, foul-smelling water. On a resident hall, multiple gnats were observed flying around residents and on surfaces throughout the corridor. Extensive observations in the kitchen revealed multiple environmental and sanitation issues that contributed to the gnat activity. Behind and around the ice machine and juice cart, there was wet dust, dirt, and organic debris such as food crumbs, sugar packets, and trash items, all saturated with moisture. Cracked, loose, and broken floor tiles near the ice machine drain and in the dish room contained food debris lodged within and beneath the damaged tiles, with standing water collected beneath the tiles and pooled around the ice machine drain. Standing water was also observed in the spray room, dish room, along walls, and in corners, with water spread across the kitchen floor after staff used a hose-mounted sprayer to clean the floors. On a subsequent day, the kitchen floor again had visible standing water, and a floor drain contained accumulated debris, paper fragments, and organic material, with a broken drain grate that did not fully cover the drain and exposed additional trapped debris; gnats were present in and near this drain and throughout the kitchen. Review of facility work orders showed only one report of gnats in common areas and nursing units for one month and one report of bugs facility-wide in the following month, despite the widespread activity observed. Service reports from the contracted pest control company over several months documented ongoing, unresolved environmental concerns in the kitchen and adjacent areas, including repeated findings of drain debris, standing water in kitchen and dishwashing areas, debris accumulation, and moisture issues that remained uncorrected by the facility. The pest control representative and pest control account manager both stated that gnats were originating from drains, cracks, and crevices with organic debris and moisture, and that routine cleaning practices were ineffective when debris remained or was pushed into cracks and around drains. They reported that recommendations such as debris removal, proper drain maintenance, and cleaning of hard-to-reach areas were repeatedly communicated and documented, but the facility’s compliance with these recommendations was inconsistent, with many action items left undone and carried over on subsequent service reports. Interviews with staff and leadership further described the facility’s actions and inactions related to pest control and sanitation. The Dietary Manager reported ongoing gnat concerns for multiple weeks, stated that pest control services were provided twice monthly, and that kitchen staff performed routine cleaning weekly and as needed, using a hose-mounted spray system for floors and pouring vinegar down drains between pest control visits. The pest control representative stated that pouring vinegar down drains would not eliminate the infestation and might attract gnats, as it did not remove organic buildup or kill larvae. The pest control account manager identified contributing factors such as debris buildup in cracks and flooring, lack of routine cleaning behind equipment, standing water or improperly maintained mop buckets, inconsistent cleaning practices in non-visible areas, and lack of routine maintenance of drains and traps, and noted that environmental cleaning often improved only after issues became more apparent. The VPO acknowledged gnat activity throughout the building and that pest control reports had identified ongoing debris concerns in the kitchen, but could not clearly describe a process to ensure consistent cleaning of hard-to-reach areas or to verify cleaning effectiveness. The DON and Administrator described expectations for reporting pests, emptying mop buckets, removing trash from medication carts, removing debris before floor cleaning, and not sweeping debris into drains, but these expectations were not reflected in the observed conditions. Two cognitively impaired and intact residents reported that gnats were always present, especially around meal times and food, and that they found them bothersome and undesirable during meals.
Failure to Provide Two-Person Assistance During Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance to prevent a fall for one resident who had diagnoses of morbid obesity, left foot drop, and right foot drop. The resident’s care plan identified a need for two staff members for bed mobility and in-bed care related to bariatric status, and also directed staff to provide two-person assistance for bed mobility and total assistance for incontinence care as the resident allowed. The resident’s MDS indicated intact cognition and that the resident required supervision or touching assistance for rolling left and right in bed. During incontinence care, the resident slid off the edge of the bed to the floor and onto their knees. The acute change in condition assessment documented abrasions and skin discoloration after the incident. In interviews, the resident stated that a staff member rolled them out of bed during incontinence care and that they were able to assist with rolling by using the assist bars on either side of the bed. The resident stated that while rolling to the right side of the bed, they rolled too far and slid off the edge of the bed while the SRNA was standing on the opposite side of the bed. Staff interviews showed that the SRNA provided the incontinence care by herself even though the resident required two-person assistance. The SRNA stated she did not ask another staff member for help because she was used to performing the care alone, and later stated that having another SRNA in the room could have prevented the incident. Other staff, including the ADON and DON, stated the resident should have had two staff members assist with incontinence care. The DON also stated the resident could assist with turning using the bed rails, but the SRNA should have used another staff member and waited for assistance.
Insulin Pen Competency Not Demonstrated
Penalty
Summary
Licensed nursing staff were not shown to have the competencies and skill set necessary to administer insulin via an insulin injector pen for one LPN observed caring for a resident with diabetes. Review of the LPN’s competency assessment showed the DON assessed insulin administration by syringe, but it did not indicate assessment of insulin pen injector use, even though the competency document stated staff should have access to manufacturer instructions for all insulin delivery systems before use. The manufacturer’s instructions for NovoLog FlexPen required priming the pen before injection to avoid injecting air and ensure proper dosing. The resident involved was admitted with a diagnosis of type 2 diabetes mellitus with hyperglycemia and had active orders for NovoLog FlexPen, including a sliding scale order and a separate order for 16 units before meals. During observed medication administration, the LPN checked the resident’s blood glucose, which was 409, then administered 16 units of NovoLog FlexPen without priming the pen needle. After contacting the physician, the LPN later returned and administered 10 units from the sliding scale order, again without priming the insulin needle. The LPN stated she was not aware the pen needle needed to be primed and was unsure whether she had education on insulin pen injectors. The DON stated competency training covered insulin administration by syringe but not insulin pen injectors, and the Administrator stated the facility had not provided competency training related to insulin pens.
Failure to Provide Ordered PT/OT and Document Missed Therapy Sessions
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered for one resident admitted for rehabilitation with diagnoses of muscle weakness and unsteadiness on feet. The resident’s care plan, initiated shortly after admission, identified a rehabilitation focus with skilled PT and OT interventions, and physician orders specified PT and OT to evaluate and treat. The OT plan of care called for treatment five times per week for 60 days, and the PT plan of care called for treatment five times per week for 30 days. Review of the Service Log Matrix showed that the resident did not receive individual PT or OT on two specified dates, despite the plan of care requiring therapy five days per week. The Director of Rehabilitation confirmed that the resident missed PT/OT on those two dates, that the plan of care was for five days a week, and that the resident only received PT/OT three out of five days for two consecutive weeks. The resident and the resident’s representative reported concerns that the resident was not receiving the allotted amount of therapy time and that therapy was not tailored to the resident’s specific needs. The representative stated the resident was weaker upon discharge than at admission and that the family sought transfer to another facility for PT after expressing concerns without improvement. The resident reported not receiving any PT during the first week, receiving PT only after questioning staff, and that when PT was provided it lasted 30–40 minutes and included group therapy that was counted as PT despite the resident’s preference against group therapy. The Director of Rehabilitation stated she did not know why therapy was missed on the two identified dates and that no reasons were documented, although such reasons were typically recorded. The DON stated her understanding that if therapy was missed, staff should attempt to reschedule so that residents did not miss needed therapy, and the current Administrator stated her expectation that residents receive the therapy they are supposed to receive to reach their maximum potential.
Failure to Maintain Clean, Safe Laundry Environment and Proper Handling of Resident Clothing
Penalty
Summary
The facility failed to ensure a safe, clean, sanitary, and comfortable environment in the laundry area as required by its Safe and Homelike Environment and Resident Rights policies. The policies stated that the physical layout should not pose a safety risk and that a sanitary environment must be maintained, including proper cleaning and storage of resident care equipment and items used for activities of daily living. Despite these policies, observations on 04/17/2026 showed the floor between and behind the washing machines covered and caked with dirt, a dry flaky substance, loose concrete, and residue on piping and chemical tubing, while multiple buckets of corrosive laundry chemicals and detergents were present in the same area. A resident’s family member reported that during the resident’s four‑day stay, most of the resident’s clothing was lost, and when she was allowed into the laundry room to search for the items, she found the room extremely hot, messy, with clothes everywhere, dirty conditions, and overflowing trash. The resident involved had significant medical diagnoses including COPD, acute on chronic systolic heart failure, type 2 diabetes mellitus, and end‑stage renal disease. A SRNA corroborated that the laundry room had always been hot, especially in summer, and that the room had long been somewhat messy with clothes, worsening over the past couple of years. Interviews with housekeeping, environmental services, the chemical supplier, and maintenance staff revealed that a chemical spill behind the washing machines had occurred well over a year earlier when ports at the back of the machines became clogged, causing chemicals to leak onto the floor. The chemical representative stated he cleaned the ports and moved tubing, and an EVS staff member told him maintenance would clean up the spill, but it was never done. Housekeeping reported that maintenance told them to clean up the spill themselves, while the Maintenance Director stated that EVS was responsible for cleaning the washing machines and that he had not observed leaks during his tenure. The dried, flaky substance and damaged concrete remained in place until it was later cleaned and repaired, and there was no documented system in place to ensure regular cleaning behind the washers, despite the presence of paper checklists for other tasks such as lint trap cleaning.
Failure to Timely Report Alleged Physical Abuse to State Agency and Law Enforcement
Penalty
Summary
The facility failed to report an allegation of physical abuse to the state survey agency and law enforcement within the required two-hour timeframe. Facility policy titled “Abuse Prohibition Standard of Practice,” last reviewed 03/2026, required that alleged violations be reported immediately to the Administrator or designee and to the state survey agency, adult protective services, and other required agencies, including law enforcement when applicable, within specific time frames. The policy also required the Administrator or designee to report suspicion of a crime to local law enforcement authorities. Resident 94, admitted on 06/19/2025, had a medical history including anemia, difficulty in walking, dislocation of an internal right hip prosthesis, muscle weakness, and other symbolic dysfunctions. An admission MDS with an ARD of 06/24/2025 showed a BIMS score of 10, indicating mild cognitive impairment, and the care plan documented impaired cognition and psychosocial adjustment difficulties related to anemia. On 07/01/2025, the facility generated an Initial Report indicating that a family member reported the resident had stated someone smacked them across the face the previous day after lunch or dinner. The Administrator was notified of this allegation at 9:45 AM. An email from the Administrator to the state survey agency showed the initial report was sent at 1:41 PM, more than three and a half hours after the Administrator was notified, exceeding the two-hour reporting requirement. The Initial Report did not indicate that local law enforcement was notified. During interviews, the SSD, DON, and Administrator all acknowledged that allegations of abuse should be reported to the state survey agency within two hours, and the Administrator stated that their process was to notify law enforcement when a resident requested or when there was a chance a law had been broken, but she did not follow the appropriate process in this case.
Failure to Conduct Comprehensive Abuse and Misappropriation Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct prompt, comprehensive investigations into allegations of abuse and misappropriation of resident property, contrary to its Abuse Prohibition Standard of Practice policy. That policy required the administrator or designee to oversee internal investigations of all alleged violations of abuse, neglect, exploitation, misappropriation of resident property, and injuries of unknown origin, including interviews of all involved persons and others who might have knowledge of the allegations. For one resident, the facility did not interview the staff member specifically named by the resident as the alleged perpetrator of misappropriation, despite documentation showing that a staff member with that first name was scheduled and worked during the timeframe of the alleged incident. For another resident, the facility did not obtain statements from all staff who worked during the relevant shifts and did not interview or obtain statements from office staff, even though the allegation involved a manager in an office area. One resident, admitted with diagnoses including aftercare following removal of a knee joint prosthesis, generalized anxiety disorder, and major depressive disorder, had a BIMS score of 13 indicating intact cognition, but was also care planned for progressive decline in intellectual functioning, memory deficits, and anxiety with agitation. This resident reported that $350, a driver’s license, and an insurance card were missing from their wallet or purse and identified by first name the person they believed took the items. The facility’s initial and final reports to the state survey agency documented the allegation and noted that no cash was recorded on the admission inventory and that no staff by the alleged name worked on the day the allegation was reported. However, the facility’s monthly schedule showed that an SRNA with the same first name as the alleged perpetrator was scheduled and worked the evening and night shift spanning the date of the alleged incident. The investigation packet contained 20 staff statements, but no statement from this SRNA or from any staff member with the alleged first name. The SSD stated she obtained statements from everyone who worked that day and did not interview the SRNA because she believed the SRNA did not work that day, while the SRNA later confirmed she had worked that shift, knew the resident, and was never asked for a statement. The DON acknowledged she did not interview the SRNA, was unaware of the investigative process, and did not know if there was a process for investigating such allegations, and the Administrator, who was the Abuse Coordinator, confirmed that the SRNA was not interviewed despite the resident naming a staff member with that first name. Another resident, admitted with diagnoses including anemia, difficulty in walking, dislocation of an internal right hip prosthesis, muscle weakness, and other symbolic dysfunctions, had a BIMS score of 10 indicating mild cognitive impairment and was care planned for impaired cognition and psychosocial adjustment difficulties. This resident’s family member reported that the resident said someone smacked them across the face after a meal, and a typed SSD statement documented that the family member reported the resident said the manager over the office smacked them. The facility’s final report stated that the resident reported being slapped in a hall after a meal, could not identify the meal or describe the individual, and said they reported the incident to an employee in the back office. The investigation packet included 17 staff statements from floor staff (SRNAs, LPNs, and RNs) but no statements from any office staff, despite the allegation involving a manager over the office and a report to an employee in the back office. Daily staffing guides showed that 34 different floor staff worked during the two 12-hour shifts on the day of the alleged incident and the following day shift, yet statements were not obtained from multiple identified RNs, LPNs, SRNAs, and KMAs who worked those shifts. The facility conducted skin assessments and interviews only for residents on the hall where the resident resided and did not complete resident interviews or skin assessments for residents on other halls. In interviews, multiple staff who had worked during the relevant timeframe stated they were never asked about any resident being slapped or asked to provide statements. The DON stated that her role in abuse investigations was to perform skin assessments and obtain staff statements, believed that therapy and office staff had been interviewed, and did not review surveillance cameras, while the Administrator stated they narrowed the investigation and did not review cameras because they only showed hallways and not the back hallway where offices and therapy areas were located. Overall, for both residents, the facility did not follow its own policy requirement that investigations be prompt, comprehensive, and include interviews of all involved persons and others who might have knowledge of the allegations. In the misappropriation case, the named SRNA who worked during the alleged timeframe was not interviewed or asked for a statement, and the DON acknowledged lack of familiarity with the investigative process. In the physical abuse case, the facility did not obtain statements from all staff who worked during the relevant shifts, did not interview office staff despite the allegation involving an office manager and a report to a back office employee, and limited resident assessments and interviews to one hall, without extending them to other halls where potential witnesses or victims might have been located. These omissions in investigative steps led to incomplete investigations of the reported allegations of abuse and misappropriation of property for the two residents.
Failure to Follow Two-Person Assist Care Plan Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident who required extensive assistance with activities of daily living (ADLs). The facility’s policy required development and implementation of care plans with measurable objectives and time frames to meet residents’ medical, nursing, mental, and psychosocial needs. The resident was admitted with osteoporosis, a right artificial hip joint, and dementia, and was assessed on a quarterly MDS as severely cognitively impaired, rarely or never understood, and dependent for bed mobility, toileting, and transfers. The resident’s care plan/kardex identified an ADL problem and included an intervention requiring two staff to assist with bed mobility, toileting, and transfers. On the day of the incident, a state registered nurse aide (SRNA) began providing perineal care to the resident and rolled the resident onto her left side without waiting for a second staff member, despite knowing the resident was care planned as a two-person assist. When the SRNA rolled the resident, the resident rolled out of bed and fell to the floor on her right side. The incident report documented that the root cause of the fall was the resident being rolled too far over, causing her to roll out of bed. Staff interviews confirmed that the resident had been a two-person assist for years and that there had been no changes to the care plan on the day of the incident. Following the fall, an LPN assessed the resident, notified the nurse practitioner, and obtained stat x-rays, which revealed a right femoral diaphyseal fracture with complete displacement and foreshortening, and an orthopedic consult was recommended. Hospital imaging later confirmed a comminuted and moderately displaced mid to distal right femoral shaft fracture, and the surgical team repaired the resident’s hip. Hospital documentation showed that the resident subsequently died while on the hospital’s hospice unit. Interviews with the SRNA, LPN, unit manager, infection preventionist/acting DON, and the administrator consistently indicated that staff were trained to follow the care plan/kardex and that the resident’s two-person assist requirement was known, but in this incident the care plan intervention was not followed.
Failure to Follow Two-Person Assist Care Plan Resulting in Fall and Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance during care, resulting in a fall with fracture for one resident. The resident was admitted with osteoporosis, a right artificial hip joint, and dementia, and was assessed on the Quarterly MDS as severely cognitively impaired and rarely/never understood. The MDS further documented the resident as dependent for bed mobility, toileting, and transfers. The resident’s care plan, as reflected on the Kardex, identified an Activities of Daily Living (ADL) problem and included an intervention requiring two staff to assist with bed mobility, toileting, and transfers. On the day of the incident, an SRNA began providing perineal care to the resident alone, despite knowing the resident required a two-person assist. The SRNA rolled the resident onto her left side, which caused the resident to roll out of bed on her right side onto the floor next to the other bed in the room. The incident report documented that the root cause was the resident being rolled too far over during care, and the IDT determined that the SRNA failed to follow the resident’s Kardex. At the time of the incident, the resident had predisposing physiological factors of weakness and situational factors including a history of falls. Following the fall, an LPN and the unit manager responded to the room and found the resident lying on her right side on the floor, with no apparent distress or obvious injury initially observed. The LPN documented notification of the NP and family and obtained orders for x-rays of the right shoulder, hip, and knee. Mobile x-ray results showed a right femoral diaphyseal fracture with complete displacement and foreshortening, and an orthopedic consult was recommended. The resident was subsequently sent to the hospital, where imaging confirmed a comminuted, moderately displaced mid to distal right femoral shaft fracture, and an ORIF procedure with plate and screw fixation was performed. The resident later expired in the hospital’s hospice unit. Interviews with the SRNA, LPN, another SRNA, the unit manager, the acting DON/IP nurse, and the administrator consistently confirmed that the resident had long been a two-person assist and that only one staff member was present providing care at the time of the incident, contrary to the care plan and Kardex. Staff interviews further revealed that, prior to the incident, nurses and unit managers did not routinely spot check SRNAs to ensure they were following the care plan/Kardex when providing care. The SRNA involved acknowledged she had been trained during orientation to follow the care plan/Kardex and admitted she did not follow it in this case, stating she started care alone while expecting her partner to join later. The LPN, another SRNA, the unit manager, the acting DON/IP nurse, and the administrator all stated that the resident’s care plan and Kardex required two staff for bed mobility and related ADLs and that there had been no change to this requirement on the day of the incident. The administrator and acting DON/IP nurse both stated it was their expectation that staff follow the care plans and Kardex when providing care, and the administrator confirmed that only one staff member was present when the incident occurred.
Delayed Administration of Ordered Antibiotic for UTI
Penalty
Summary
The deficiency involves the facility’s failure to provide timely pharmaceutical services and administer an ordered antibiotic for a resident with a suspected urinary tract infection (UTI). The resident, who had intact cognition and diagnoses including arthropathic psoriasis and morbid obesity, was care planned for elimination deficits with interventions such as PRN straight catheterization for urinalysis and monitoring for UTI signs and symptoms. On one occasion, the resident developed a fever of 102°F, and a urinalysis showed significant abnormalities, including 3+ leukocytes, 3+ bacteria, and red blood cells too numerous to count. Based on these findings, the nurse practitioner ordered a single 3 g dose of Fosfomycin to treat the UTI while awaiting culture results. The medication order for Fosfomycin was entered with a start date of the day after the follow-up note, but the drug was not administered as ordered. The MAR showed that the Fosfomycin was to be given one time by mouth for UTI, and a subsequent entry documented that the medication was on hold because it was not available from the pharmacy. There was no documented physician order to hold the medication, and no progress note was found explaining the delay, who was contacted, or what actions were taken when the medication was reportedly unavailable. The Fosfomycin was ultimately documented as administered four days after the original order date, indicating a significant delay in treatment. Interviews and record reviews further clarified the circumstances leading to the deficiency. The infection preventionist stated that the facility followed McGeer criteria for antibiotic use and that the urinalysis did not meet those criteria, but he was not aware of this specific incident. The DON stated she did not know why the Fosfomycin was not given as ordered, noted that this medication was commonly used and readily available from the pharmacy, and confirmed it was not stocked in the emergency medication supply. The DON also stated her expectation that medications be received timely from the pharmacy and administered to residents, and that any delay in antibiotics could possibly lead to sepsis and pain. The resident reported having gone without treatment for approximately three weeks after developing a UTI, stated she never received the originally ordered one-time antibiotic dose, and later required transfer to the emergency department where she was diagnosed with a complicated UTI and treated with IM Rocephin and Toradol for pain.
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